Basic Information
| Provider Information | |||||||||
| NPI: | 1891170882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TALLY | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | |||||||||
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| Credential: | B.A., QMHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 FREMONT ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975202537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414825792 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1836 FREMONT ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975202537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414825792 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2015 | ||||||||
| LastUpdateDate: | 07/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.